What is the differential diagnosis and management for a pediatric patient presenting with epigastric pain and hematuria (Red Blood Cells in urine)?

Differential Diagnosis and Management of Pediatric Epigastric Pain with Hematuria

In a pediatric patient presenting with epigastric pain and hematuria, the primary differential diagnosis is urolithiasis, followed by ureteropelvic junction obstruction, renal trauma, and less commonly, peptic ulcer disease with concurrent renal pathology. 1

Immediate Clinical Assessment

Critical History Elements

• Trauma history: Even minor trauma to an anomalous kidney can cause major clinical repercussions (renal anomalies occur in 1-4% of the population) 1
• Pain characteristics: Colicky flank pain radiating to groin suggests urolithiasis; sudden severe epigastric pain with fever and rigidity suggests perforation (mortality up to 30%) 2, 3
• Family history: Nephrolithiasis or metabolic disease predisposes to stone formation 1
• Associated symptoms: Nausea, vomiting, dysuria, frequency, fever, or hematemesis 1

Physical Examination Priorities

• Vital signs: Hypotension, tachycardia ≥110 bpm, or fever ≥38°C predict serious complications 4
• Abdominal examination: Peritoneal signs (rigidity, rebound, absent bowel sounds) mandate immediate surgical consultation 2
• Costovertebral angle tenderness: Suggests renal pathology 1
• Blood at urethral meatus: With pelvic trauma indicates 50% incidence of genitourinary injury 1

Urinalysis Interpretation

Hematuria Classification

• Macroscopic (gross) hematuria: Necessitates radiologic evaluation of abdomen and pelvis 1
• Microscopic hematuria ≥50 RBCs/HPF: Requires imaging in trauma or with concerning mechanism 1
• Microscopic hematuria <50 RBCs/HPF: In trauma without hypotension or concerning mechanism, imaging may not be required 1

Additional Urinalysis Findings

• Proteinuria >2+ with RBC casts and dysmorphic RBCs: Suggests glomerular disease (glomerulonephritis), not structural pathology requiring imaging 1
• White cells and organisms: Indicates urinary tract infection, directing different management 1
• Spot urine calcium-to-creatinine ratio: Evaluates for hypercalciuria predisposing to stones 1

Differential Diagnosis by Clinical Scenario

Painful Hematuria (Non-Traumatic)

Primary consideration: Urolithiasis 1

• Pediatric stone disease incidence is rising; affected children may have family history or metabolic disease 1
• Critical caveat: Many pediatric patients with urolithiasis do NOT have hematuria 1
• Secondary considerations: UPJ obstruction, tumor 1

Epigastric Pain with Hematuria (Non-Traumatic)

This combination is unusual and requires broad differential:

• Peptic ulcer disease with concurrent renal pathology: Occult blood in stool indicates GI bleeding (most common PUD complication); hematuria suggests separate renal process 2
• Nutcracker syndrome with gastric compression: Aortomesenteric angle narrowing can cause both duodenal compression (epigastric pain, vomiting) and left renal vein compression (hematuria) 5
• Henoch-Schönlein purpura: Can cause both abdominal pain and glomerular hematuria 1

Traumatic Hematuria

• Macroscopic hematuria post-trauma: 59 renal injuries identified in 334 pediatric blunt trauma patients with gross hematuria, shock, or significant deceleration 1
• Microscopic hematuria with hypotension or concerning mechanism: Warrants imaging 1
• Renal artery thrombosis: Can present with flank/epigastric pain and proteinuria; hematuria may be absent 6

Imaging Algorithm

First-Line Imaging: Ultrasound

Ultrasound of kidneys and bladder is the initial imaging modality for most pediatric hematuria scenarios 1

• Displays kidney anatomy, size, position (especially before biopsy) 1
• Screens for structural lesions, hydronephrosis, masses 1
• Limitation: Limited sensitivity for stones (found 75% of all urinary tract stones but only 38% of ureteral stones) 1
• Radiation-free: Critical consideration in pediatric population 1

CT Abdomen/Pelvis with IV Contrast

Indications for CT:

• Painful hematuria with negative ultrasound and high clinical suspicion for urolithiasis 1
• Macroscopic traumatic hematuria: All CT scans must use IV contrast unless specifically contraindicated 1
• Peritoneal signs or suspected perforation: CT shows extraluminal gas (97%), fluid/fat stranding (89%), ascites (89%), focal wall defect (84%) 4, 3
• Epigastric pain with unclear diagnosis: Gold standard for identifying pancreatitis, perforation, vascular emergencies 4, 3

CT advantages:

• Sensitivity and specificity >90% for stone detection 1
• Not impaired by small stone size, bowel gas, or poor sonographic window 1
• Low-dose protocols with iterative reconstruction achieve doses less than traditional IVU 1

When Imaging is NOT Indicated

• Isolated microscopic hematuria without proteinuria or dysmorphic RBCs: Unlikely to have clinically significant renal disease 1
• Isolated microscopic hematuria <50 RBCs/HPF post-trauma without hypotension or concerning mechanism: Significant renal injuries unlikely 1

Laboratory Evaluation

Essential Initial Tests

• Urinalysis with microscopy: Quantify RBCs, assess for casts, dysmorphic RBCs, proteinuria, WBCs 1
• Urine culture: If infection suspected 1
• Complete blood count with platelets: Assess for anemia from bleeding, rule out coagulopathy 1
• BUN and serum creatinine: Evaluate renal function 1
• Spot urine calcium-to-creatinine ratio: Screen for hypercalciuria 1

Additional Tests Based on Clinical Suspicion

• Serum amylase or lipase: If pancreatitis suspected (≥4x normal for amylase or ≥2x normal for lipase has 80-90% sensitivity/specificity) 4, 3
• Stool occult blood: If GI bleeding suspected with PUD 2
• ECG and serial cardiac troponins at 0 and 6 hours: If any concern for atypical cardiac presentation (never dismiss cardiac causes regardless of age) 4, 3

Management Priorities

Immediate Actions

1. Assess hemodynamic stability: IV access and fluid resuscitation if unstable 4
2. Maintain NPO status until surgical emergency excluded 4
3. Immediate surgical consultation if peritoneal signs develop 2

Empiric Medical Management

• High-dose PPI therapy (omeprazole 20-40 mg once daily) for suspected acid-related pathology (healing rates 80-90% for duodenal ulcers, 70-80% for gastric ulcers) 4, 3
• Avoid NSAIDs: Worsen PUD and bleeding risk 4
• Antiemetics for symptomatic relief: Ondansetron 8 mg sublingual every 4-6 hours (obtain baseline ECG due to QTc prolongation risk) 4

Definitive Diagnosis

• Upper endoscopy: Definitive for PUD, gastritis, esophagitis when patient is stable; allows direct visualization, histopathology, and H. pylori testing 2, 3
• Renal biopsy: May be necessary for glomerular diseases (IgA nephropathy, Alport syndrome) after ultrasound confirms kidney size/position 1

Critical Pitfalls to Avoid

• Do not assume hematuria correlates with injury severity: 36-40% of renal injuries and up to 24% of renal artery occlusions have no hematuria 1
• Do not delay imaging in macroscopic traumatic hematuria: Renal salvage time is limited (successful revascularization possible up to 12 hours post-injury) 6
• Do not miss perforation: Mortality increases significantly with delayed diagnosis; sudden severe pain with fever and rigidity mandates immediate CT and surgical consultation 2, 3
• Do not overlook cardiac causes: Myocardial infarction can present with isolated epigastric pain, especially in atypical populations 4, 3
• Do not perform extensive imaging for isolated microscopic hematuria without proteinuria: These patients are unlikely to have significant renal disease 1